General Confidentiality Agreement

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General Confidentiality Agreement Powered By Docstoc
					                                Purdue University
                           Confidentiality Agreement
                           Clinical Training Programs
Purdue University periodically allows certain students, trainees or heath care
practitioners to participate in approved training programs conducted by the Purdue
Student Health Center for educational purposes. I understand that I have been
authorized to observe or participate in an approved clinical training program. I
further understand that in the course of my participation, I will likely encounter
confidential information and information protected by HIPAA. This confidential
or protected health information may come from a number of sources including, but
not limited to, electronic media, medical records, verbal interactions and general
observations. I understand that I must be accompanied by my medical supervisor
or the program trainer at all times, and that I will not speak with patients or access
any confidential information or medical charts without the express approval of my
medical supervisor or program trainer.
I understand that all health information I encounter is strictly confidential, and I
agree that I am prohibited from disclosing or giving access to any confidential
health information to anyone outside the program. I agree not to discuss
confidential health information with anyone other than my medical supervisor,
trainer or others in the program, as necessary, to complete the objectives of the
program. I also agree to access, use and disclose (within the program) only the
minimum protected health information necessary to complete the objectives of the
program. Any breach of confidentiality under this Agreement may result in
notification of misconduct to the individual’s sponsoring clinical organization and
removal from any further training programs conducted by the Purdue Student
Health Center.

By signing below, I certify that I have received and reviewed training concerning
the HIPAA Privacy Regulations, and that I will abide by the terms of this
Confidentiality Agreement and applicable Purdue policies and procedures to
ensure appropriate confidentiality and security of the health information that I
encounter while participating in a clinical training program.
_______________________________               ______________
Signed                                        Date
Sponsoring Organization

                               Page 1 of 1              Last Revision 06/26/2008

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